Recurring violence against adolescents: an analysis of notifications

Abstract Objective: to identify the frequency of reported cases of recurring violence against adolescents and their association with victim, violence, and aggressor characteristics. Method: cross-sectional study conducted with notified data on violence against adolescents, produced by Epidemiological Surveillance and registered in the Information System of Diseases and Notification (SINAN), from 2011 to 2018, in the state of Espírito Santo, Brazil. Results: the frequency of recurring violence against adolescents was 46.4%. Higher occurrence was observed among girls (PR: 1.26; 95%CI: 1.15 - 1.38) between 10 and 14 years of age (PR: 1.20; 95%CI: 1.13 - 1.28), and people with a disability or disorder (PR: 1.52; 95%CI: 1.42 - 1.62). Psychological violence/neglect was 30% more prevalent in recurrence than self-harm. Most cases occurred at home (PR: 1.56; 95%CI: 1.37 - 1.77). Results showed a 1.11 times higher prevalence of recurring violence perpetrated by aggressors aged 20 years or older and higher evidence in male aggressors (95%CI: 0.97 - 1.17). Conclusion: recurring violence was associated with victim, aggressor, and event characteristics. Health intersectoriality is crucial to reduce cases of recurring violence.


Introduction
Violence against adolescents manifests itself in many ways, whether perpetrated by parents, other caregivers, colleagues or strangers in this life cycle, individuals are exposed to self-harm; domestic abuse and neglect by parents and caregivers; to youth violence outside the home, often in schools, in the community, or online; and intimate partner violence or dating violence, which occurs among adolescents involved in romantic relationships (1) .
Regardless of its form, violence is a traumatic event that has negative individual, social, and economic impact (2) . Depending on its occurrence -chronic or recurrent -, consequences can be dire. One of the most disturbing aspects of child abuse is its tendency to recur (3) .
The literature points out that recurrence of violence refers to circumstances in which victims who have previously been proven victims of abuse or neglect experience another incident of proven abuse (4) .
In 2017, Brazil recorded 79,914 reports of violence against adolescents, of which 30.9% were recurring cases and most were perpetrated in domestic settings.
The Southeast region, in the same year, recorded 36,521 cases of violence, of which 29.5% were repeat cases (5) .
Recurrence has multiple and significant negative effects on children and adolescents who are abuse victims (4) . Regarding sexual violence, one study concluded that those who experience a childhood episode of sexual abuse exhibit more risky sexual behaviors and are more likely to experience further episodes of sexual victimization during adolescence and early youth (6) .
Moreover, adolescent victims of recurrent violence tend to experience more episodes of violence at school, more aggression in the community, and further transgress social norms. They also have less social support, lower resilience and low self-esteem (7)(8) .
Recurrence of abuse is of great interest for protection services to victims of violence (3) , context in which health professionals, especially nurses, play an important role in identifying cases of acute or chronic violence for better referral of victims in the health care network, aiming at resoluteness and comprehensive care. This identification by nurses also provides subsidies for organization and performance of the social protection network for adolescents (9) . Besides, case reporting contributes to the epidemiological dimensioning of the issue, which allows apprehending the dynamics of this violence, and then developing and creating specific programs and actions, as well as public policies aimed at its prevention (10) .
Given this context, this study sought to identify the frequency of reported cases of recurring violence against adolescents and their association with victim, violence, and aggressor characteristics.

Study design
This is a cross-sectional observational analytic study (11) .

Location
The study took place in the state of Espírito

Population and study period
The research was conducted with notified data on violence against adolescents, between 10 and 19 years The World Health Organization (WHO) defines adolescence as the period of life beginning at age 10 and ending at age 19. For the WHO, adolescence is divided into three phases: early (10-13 years), middle (14-16 years) and late (17-19 years) adolescence (12) .

Study variables
Dependent variable was recurring violence (yes or no). Independent variables included victim characteristics: gender (male and female), age group

Data analysis
Data were analyzed using descriptive statistics in raw and relative frequency with 95% confidence intervals. Bivariate analyses were performed using Chi-Square test (χ²), with a significance level of 95%, and adjusted analysis using Poisson's regression with robust variance. All independent variables with p< 0.20 were included in the model. Permanence occurred when p < 0.05.

Results
From 2011 to 2018, the state of Espírito Santo recorded a total of 3,094 cases of recurring violence against adolescents, that is, a frequency of 46.4%.
Data showed a higher frequency of violence perpetrated by a single person (86.3%), mainly male (57.8%), up to 19 years old (55.6%). In 48% of the cases, the aggressor was a family member. In most cases (76.5%), the aggressors were not suspected of having consumed alcohol before the assault (Table 1).    (14) . Another research states that women were victims of recurring violence to a greater extent than men (13) .
This higher prevalence of recurring violence among women can be explained by historical and cultural factors, which imposed conditions of abuse, exploitation, subordination and discrimination on women, resulting in current gender issues that place girls at higher risk of exposure to violence and its recurrence (15)(16) .
Adolescent girls bring with them a movement of freedom and search to overcome femininity stereotypes.
International literature has been reporting the developmental perspective related to gender and violence within intimate relationships (17) . Intimate relationships usually begin in adolescence, and their knowledge concerning these relationships is tied to the media, as well as to the observation of friends and family. Such a process is permeated by narcissism, an attachment to gender-specific roles, and the mystification of romantic love, leaving this population vulnerable to intimate partner abuse (17) . This perspective is also addressed by a metaanalysis on the prevalence of violence in intimate physical and sexual relationships among adolescents, and its associated factors (18) .
A study conducted with secondary data from Sample II of the National School Health Survey (PeNSE 2015), pointed out that among adolescent victims of intrafamily violence, those in the youngest age group (13 to 15 years old) had higher prevalence of recurring violence (P: 8.6%. 95%CI: 7.6 -9.6) when compared with older adolescents (19) .
The higher number of cases of violence against younger age groups is justified due to their inability to escape and/or defend themselves. Moreover, physical and personality fragility makes adolescents easy targets of violence and contributes to the chronicity of such abuse (14,20) .
Younger adolescents are physically, psychologically and socially more vulnerable, lacking maturity to understand the web created by the aggressor to exert violence (21) . Besides, they are more likely to experience violence because they spend more time at home with their families when compared to older age groups, who generally spend more time outside their homes (19) .
International studies have addressed adolescents living in high vulnerability urban regions, and point to statistically significant differences in the understanding and coping of this vulnerable population regarding violence in intimate relationships (18,22) . The context of social vulnerability can expose adolescents to situations of violence with negative repercussions for their lives.
A systematic review that summarized and evaluated data on the causes and consequences of dating violence among adolescents, pointed out that poverty is an important factor for its occurrence (23) . It also suggested that financial hardship and low income also increase the risk of violence in intimate relationships (24) .
A qualitative study that aimed to understand and  (13) . Both are difficult to register due to their characteristic subjectivity and different expressions, being generally associated with other forms of violence (26)(27) .
In the present study, the higher prevalence of recidivism of violent behavior was associated with having some type of disability and/or disorder (PR: 1.52; 95%CI:  (13) showed that about 57% of the cases took place at home, pointing to this space as a common place for violence to emerge.
The victim's home is seen as a privileged environment for the occurrence of multiple episodes of violence against adolescents, since the limits imposed by the physical and social privacy of the environment isolate the family from the public eye, providing a place without witnesses and covered up by family complicity (14) .
Regarding the aggressors' characteristics, we observed a higher prevalence of recurring violence perpetuated by individuals aged 20 years or older

Conclusion
In conclusion, the study found a high prevalence of recurring violence against adolescents. The highest prevalence of this event occurred among girls, between 10 and 14 years of age, who had some type of disability and/or disorder. Psychological violence/neglect were the most frequent and committed by aggressors 20 years and older of all genders.
Given these findings, we must invest in professional training to track and address this type of violence, as well as to promote multidisciplinary humanized care and break the cycle of violence against adolescents. This serious public health issue needs to be addressed, ensuring these individuals a healthy and safe development.
We highlight the importance of joint actions between healthcare, public sectors, and civil society to reduce cases of recurring violence.
Furthermore, is of utmost importance to notify and qualify databases, since knowing epidemiological data about violence against adolescents can contribute to the dimensioning of this issue and consequently to the formulation of protection strategies for this group.